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Cross-sectional study assessing the addition of contrast sensitivity to visual

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Open Access
To cite: Spreng L, Favrat B,
Borruat F-X, et al. Cross-
sectional study assessing the
addition of contrast sensitivity
to visual acuity when testing
for fitness to drive. BMJ Open
2018;8:e018546. doi:10.1136/
bmjopen-2017-018546
► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http://dx.doi.
org/10.1136/bmjopen-2017-
018546).
Received 6 July 2017
Revised 21 November 2017
Accepted 30 November 2017
1 isolated from a loss of VA (11/162 cases had a VA ≥0.8
Doctoral School of Medicine,
Faculty of Medicine and
Biology, University of Lausanne,
Lausanne, Switzerland
2
Department of Ambulatory
Care and Community Medicine,
University of Lausanne,
Lausanne, Switzerland
3
Unit of Psychology and Traffic
Medicine, University Centre
of Legal Medicine Lausanne-
Geneva, University Hospital of
Lausanne (CHUV), Lausanne,
Switzerland
4
Ophthalmology Department,
Jules-Gonin Eye Hospital,
University of Lausanne,
Lausanne, Switzerland
5 INTRODUCTION
aR&D, School of Health
Sciences Fribourg, University
of Applied Sciences and Arts
Western Switzerland (HES-SO),
Fribourg, Switzerland
Correspondence to
Dr Paul Vaucher;
paul.vaucher@hes-so.ch
Cross-sectional study assessing the
addition of contrast sensitivity to visual
acuity when testing for fitness to drive
Lucie Spreng,1 Bernard Favrat,2,3 François-Xavier Borruat,4 Paul Vaucher3,5
ABSTRACT
Objectives The aim of this study is to quantify the
importance of loss of contrast sensitivity (CS) and its
relationship to loss of visual acuity (VA), driving restrictions
and daytime, on-road driving evaluations in drivers aged
70+.
Design A predictive cross-sectional study.
Setting Volunteer participants to a drivers’ refresher
course for adults aged 70+ delivered by the Swiss
Automobile Club in western Switzerland from 2011 to
2013.
Participants 162 drivers, male and female, aged 70 years
or older.
Clinical predictors We used a vision screener to estimate
VA and the The Mars Letter Contrast Sensitivity Test to test
CS.
Outcomes We asked drivers to report whether they
found five driving restrictions useful for their condition;
restrict driving to known roads, avoid driving on highways,
avoid driving in the dark, avoid driving in dense traffic
and avoid driving in fog. All participants also underwent a
standardised on-road evaluation carried out by a driving
instructor.
Results Moderate to severe loss of CS for at least one eye
was frequent (21.0% (95% CI 15.0% to 28.1%)) and often
decimal and a CS of ≤1.5 log(CS); 6.8% (95% CI 3.4% to
11.8%)). Drivers were more likely (R2=0.116, P=0.004)
to report a belief that self-imposed driving restrictions
would be useful if they had reduced CS in at least one eye.
Daytime evaluation of driving performance seems limited
in its ability to correctly identify difficulties related to CS
loss (VA: R2=0.004, P=0.454; CS: R2=0.006, P=0.332).
Conclusion CS loss is common for older drivers.
Screening CS and referring for cataract surgery even
in the absence of VA loss could help maintain mobility.
Reduced CS and moderate reduction of VA were both poor
predictors of daytime on-road driving performances in this
research study.
Within an ageing population, the ques-
tion of whether elderly people should be
managed differently with regard to their
driving licence is becoming more and more
relevant. The literature predicts that by
the year 2020, 20% of licensed drivers will
be older than 65 years.1 In Switzerland, in
Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546
Research
Strengths and limitations of this study
► Participants of 70 years of age or older were drivers
from the general population. We did not concentrate
on those with known health issues or those that had
known driving history.
► Drivers were free to speak openly about their health
and driving experiences, given data were collected
anonymously and there was no threat for their
licence.
► Observer bias cannot be totally excluded, given
information on visual performance and driving
restrictions was collected by the same researcher.
► The on-road driving tests were done during the day;
we cannot therefore exclude that performances
would be different with lower luminance.
2015, 1797 drivers of 70 years of age or more
were involved in a road accident with severe
injury or death (0.02% of the population).2
This population has been shown to be more
at risk. Accidents involving aged drivers are
much more likely to result in hospital admis-
sions or fatalities due to such drivers’ own
health vulnerabilities.3–6 In other words,
older drivers and health issues is more a
public health concern for their own secu-
rity rather than for others’.7 8 Being able to
drive a vehicle is, however, very important
for the autonomy, the self-esteem and the
quality of life of the elderly.1 It is linked to
a lower mortality risk.9 Without this ability,
the resulting loss of independence induces
a higher risk of isolation, depression and
associated functional impairment.9–11
In Switzerland, non-professional drivers
who are 70 years of age or older have to
undergo a compulsory medical assessment
of their fitness to drive every 2 years.12 The
law specifies that the physician is responsible
of verifying the absence of psychological,
neurological, musculoskeletal, cardiovas-
cular, respiratory or metabolic (diabetes)
disorders that could affect driving. Like
in many other countries, the legislation
1
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Open Access
also specifies that drivers’ vision and hearing must be
checked.4 12
For the elderly, health decline and visual impairments
are the most common causes that lead to driving cessa-
tion.13–16 Older drivers have difficulties adapting their
vision to low light conditions, recognising on-road
and roadside objects in low light conditions and recov-
ering from glare.17 Loss of visual acuity (VA) has been
shown to be associated with the avoidance of driving
long distances or in unfamiliar areas. Loss of contrast
sensitivity (CS) is, on the other hand, associated with
the avoidance of driving at night or in conditions
of reduced luminosity.18 At age 75+, 39.8% of female
drivers and 28.8% of male drivers report restricting
their driving due to problems with their eyesight.19
Drivers who think their vision has worsened will restrict
their driving most, even if their binocular vision is not
affected.19 Those that have a binocular CS loss <1.4
log(CS) are 2.5 (95% CI 1.2 to 3.0) times more likely to
cease driving altogether.20
High contrast VA is the most commonly used
measure of vision in assessing fitness to drive, but there
are other measures of vision such as CS that are more
discriminating. The true value of asking aged drivers
to sacrifice their mobility because they have reduced
vision is unknown, and there is no existing evidence
that supports the belief that screening VA under
photopic conditions improves road safety.10 13 21–23
A population-based survey has shown that 2.6% of
those currently driving have a VA lower than the legal
limit (<0.5 decimal) without them being more at risk
of having accidents.24 It is commonly admitted that
screening for VA alone is inappropriate for assessing
full visual function;10 it is also, at best, a very weak
means of predicting road accidents,6 24 and is also a
bad predictor of night driving ability.14 For some ocular
pathologies, cataracts, for example, CS loss might be
more influential than VA as a contributory cause of
accidents.6 24 Furthermore, drivers with a monocular
or binocular reduction of CS are more likely to be
involved in a collision that is their fault than are drivers
with reduced VA.25 For the moment, European guide-
lines and legislations provide norms and indications
for VA, ≥0.5 decimal; visual field, ≥120° ; no diplopia;
no important deterioration of twilight vision and no
major increase in glare sensitivity. But little is known
regarding the usefulness of also screening for loss of
CS, which could provide more insight into the patient’s
ability to drive at night. This would make it possible to
restrict driving to daylight conditions rather than have
people cease driving—measures that have been shown
to be effective in reducing risks.26
The aim of this study is to: (1) estimate the preva-
lence of drivers aged 70+ who are concerned by CS loss,
(2) evaluate the strength of the association between
loss of VA and CS and (3) estimate the added value of
measuring CS over VA when trying to evaluate self-regu-
lations of driving or on-road driving performance.
2 Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546
METHODS
Design
We designed an exploratory, cross-sectional, prag-
matic study combining the clinical and on-road evalu-
ation of older drivers attending a refresher course in
Switzerland.
Population
From 2011 to 2013, all residents aged 70 years or
more (n=16 858) of four regions of Vaud, Switzerland
received an invitation to participate in a refresher
course in driving competencies, provided by the Swiss
Automobile Club. Of these, 1004 participated (5.1%
of all concerned senior drivers) and were invited to
voluntarily and anonymously be screened for medical
conditions within the Guarding Aged drivers against
accidents project (GarAge). There was a 44.9% accep-
tance rate. Measurements of CS were added in October
2012. To be included in this study, participants had to
hold a valid Swiss driving licence, be community resi-
dents of the Canton of Vaud in Switzerland, be aged
70 years or older, and have CS evaluated separately for
each eye.
Visual acuity
Monocular and binocular distance VA were measured
using a vision screener called Visiotest (manufacturer
Essilor). This device has been shown to have a sensi-
tivity of 100% and a specificity of 88.1%27 to detect
vision deficiency compared with an examination of
vision carried out by an optometrist. Luminosity was
set to 320 cd/m2 with optotype contrast close to 100%.
All tests were carried out with both eyes open. We first
tested the VA of the left eye, then the right and finally
both eyes simultaneously. All tests were carried out with
optical corrections for vision at a distance—that is, to
say, patients’ glasses.
Contrast sensitivity
The Mars Letter Contrast Sensitivity Test was used to eval-
uate CS.28–30 It consists of three cardboard charts with
48 letters each. From one letter to the next, there was a
decrease in contrast of a constant factor of 0.04 log units.
The chart is held 50 cm away from the eyes. The MARS
chart has the advantage over the Pelli-Robson chart of
being smaller, more portable and more easily uniformly
illuminated.28 This test is at least as reliable or more so
than the Pelli-Robson test.28–30 In our study, we decided
to set the threshold for detecting moderate to severe
contrast loss for CS at <1.5 log(CS).31 32
Ancillary tests
In addition to VA and CS, we also evaluated horizontal
visual fields; visual processing, using the useful field of
view (UFOV);33 overall cognitive function, using the
Montreal Cognitive Assessment;34 executive function and
visuospatial search, using the Trail Making Task (parts A
and B)35 and motor function, using the Timed Up-and-Go
Test.36
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Driving history and self-imposed driving restrictions
Participants were questioned on any accidents they may
have had in the past and their average weekly distance
driven. To investigate relevant driving restriction strate-
gies, we reviewed the literature and identified 13 ques-
tions related to tactical or strategic compensations that
were reported by older drivers. These were reformulated
so that drivers could report their perceived usefulness to
their own, respective, situations, using a five-step Likert
scale (ie, essential, very useful, useful, slightly useful and
useless). We then used data from 445 drivers to derive
and test the psychometric values of questions related to
driving cessation. Item reduction was carried out using
polychoric, correlation-iterated principal factor anal-
ysis with orthogonal rotation. Items with a uniqueness
value of 0.6 or more were excluded and the analysis was
run over again. Principal component analysis revealed
a single factor with an eigenvalue of 2.62; the second
factor had an eigenvalue of 0.19. The five items for
this factor were: restrict driving to known roads, avoid
driving on highways, avoid driving in the dark, avoid
driving in dense traffic and avoid driving in fog. The
internal coherence of these items was acceptable (Cron-
bach’s alpha=0.680). The driving restriction score was
obtained by adding up the values of each individual
question about the usefulness of these specific driving
restriction strategies. The score therefore ranges from
0 to 20 with high scores corresponding to increased
self-restriction.
On-road driving evaluation
The procedure has been previously described in two
publications.35 37 Twelve driving instructors, blinded to
the clinical assessment, were engaged in the study. Each
participant drove once, with one of the instructors, on
a 45 min route on the open road, including urban and
rural sections, secondary and principal roads and high-
ways, simple and complex intersections, ‘roundabouts’
(circular intersections with changing on-road priorities),
traffic signals and complex lane selections. Instructors
reported their ‘gestalt’ evaluation of driving perfor-
mance as ‘good’ or ‘sufficient’ for the following criteria:
respecting road regulations, handling the vehicle, speed
adaptation, correct positioning on the road, comfort,
behaviour towards other road users, observation and
anticipation. Driving competencies were summarised as
excellent (no lapse), good (lapses reported for one or
two items), moderate (lapses reported for three to five
items) or poor (lapses reported for six to eight items).
This scoring method identified a unique dimension
(eigenvalue=5.1) and had a good fit to an overall trait
(R1c=12.2, df=14, P=0.565).
Statistical methods
Significance level was set at α=0.05 and all estimates are
provided with 95% CIs. Sample size was estimated with a
power of 80% to detect a determinant of correlation (R2)
of 0.25. This required a minimum of 124 participants.
Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546
Open Access
For comparability and to assure linearity for regression
analysis, both VA and CS were used on their log scale (ie,
log(minimum angle of resolution) and log(CS)).18 Asso-
ciations between VA and CS were analysed for all tested
eyes adjusting for a lack of independence of values coming
from the same individuals, using mixed-effect linear
regression. To test associations with self-imposed driving
restrictions and the on-road evaluation, we used the value
observed for both eyes, for the worst eye or the absolute
difference of values between both eyes as independent
variables. We then used linear regression analysis to test
associations with and without adjustment for possible
confounders (ie, cognitive deficits, motor deficits, age
and gender). To verify the assumption of linearity, we used
likelihood ratio tests to compare models using dependent
variables as a continuous variable instead of dichotomised
ordinal variables. We compared the added value of using
CS to VA alone using a likelihood ratio test between both
models. P<0.05 meant that CS improved the prediction of
driving restrictions or on-road performances.
Given most outcome measures were expected to be
highly correlated, no adjustments were made for multiple
testing. Only subjects with full data were included in the
analysis. All statistics were planned prior to analysis and
were run using STATA V.14.0 (Stata Statistical Software:
Release V.14.0, StataCorp).
Ethical standards
All participants provided their written, informed consent
to participate. It was performed in accordance with the
ethical standards of the 2008 amended Declaration of
Helsinki (Seoul).
RESULTS
Population description
The average acceptance rate over all four regions to
attend the refreshing course was of 5.1%. Between
Figure 1 Participant flow chart. CS, contrast sensitivity;
GarAge, Guarding Aged drivers against accidents project .
3
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Open Access

Table 1 Description of the population

All participants Both eyes with log(CS) ≥1.5 Worst eye with log(CS) <1.5
(n=162) (n=128, 79%) (n=34, 21%)
Median Median Median
Mean (SD) (p5–p95) Mean (SD) (p5–p95) Mean (SD) (p5–p95) P value*
Age 76.1 (4.73) 75.2 (70.8–84.9) 75.9 (4.64) 74.9 (70.8–84.9) 77.0 (5.0) 75.6 (70.6–88.7) 0.195
Functional mobility
TUG test (s)† 9.49 (2.65) 9.0 (6.8–15.1) 9.16 (2.32) 8.8 (6.3–13.1) 10.7 (3.38) 10.1 (6.1–16.3) 0.002
Cognitive state
MoCa (points)‡ 26.5 (2.63) 27 (21–30) 26.5 (2.53) 27 (21–30) 26.24 (2.99) 27 (19–29) 0.561
Driving
Distance (km)/ 238 (224) 200 (60–500) 234 (239) 195 (60–500) 253 (159) 225 (40–550) 0.668
week
Restriction score 2.3 (2.78) 1 (0–8) 1.88 (2.46) 1 (0–6) 3.68 (3.45) 3 (0–12) <0.001
Vision
VA bilateral§ 1.02 (0.20) 1.0 (0.6–1.2) 1.06 (0.17) 1.2 (0.8–1.2) 0.88 (0.24) 1.0 (0.4–1.2) <0.001
VA best eye§ 0.96 (0.22) 1.0 (0.6–1.2) 0.99 (0.21) 1.0 (0.6–1.2) 0.85 (2.05) 0.8 (0.6–1.2) <0.001
VA worst eye§ 0.72 (0.31) 0.8 (0.2–1.2) 0.79 (0.27) 0.8 (0.4–1.2) 0.46 (0.31) 0.4 (0.0–1.0) <0.001
Visual field¶ 183 (16) 180 (160–200) 185 (14) 180 (160–200) 179 (23) 180 (140–200) 0.059
CS bilateral** 1.72 (0.06) 1.72 (1.6–1.76) 1.73 (0.04) 1.74 (1.68–1.76) 1.66 (0.09) 1.68 (1.48–1.76) <0.001
CS best eye** 1.69 (0.06) 1.72 (1.56–1.76) 1.73 (0.04) 1.74 (1.68–1.76) 1.66 (0.09) 1.68 (1.48–1.76) <0.001
CS worst eye** 1.57 (0.25) 1.64 (1.24–1.72) 1.66 (0.06) 1.68 (1.52–1.72) 1.25 (0.38) 1.44 (0.04–1.48) <0.001
*Student’s t-test comparing groups with or without contrast sensitivity loss.
†If ≥13.5 s: functional mobility difficulties. One person could not do the test and was not assessed.
‡If <26 points: cognitive difficulties.
§In decimal.
¶Visual field in degrees.
**Expressed in log(CS): considered as normal if ≥1.5 log(CS) and restricted if <1.5 log(CS).
CS, contrast sensitivity; MoCa, Montreal Cognitive Assessment; p5, fifth percentile; p95, 95th percentile; TUG, Timed Up-and-Go Test; VA,
visual acuity.

October 2012 and September 2013, 174 older drivers
volunteered to participate in the GarAge study; complete
data proved available for 162 of them (figure 1). Visual
tests were partially available for seven of the nine drivers
who were excluded. Five had a VA of 0.8 decimal or more
for each of their eyes, one had 0.6 decimal for both eyes
and one had 0.6 decimal for one eye and 1.0 decimal for
the other. The majority of participants were men (66.7%,
n=108). One-third (35.4%) had had an incomplete educa-
tion history (<12 years of schooling). Forty-three of the
drivers (26.5%) had been involved in an accident during
the previous 2 years; eight drivers had had to file a claim
on their vehicle insurance and only one accident caused
injury. Driving instructors considered 46.4% of drivers
to have excellent driving competencies, 30.0% to have
good competencies, 16.3% to have moderate competen-
cies and 7.3% to have poor competencies. Having good
or moderate competencies did not prevent drivers from
considering self-imposed driving restrictions useful; only
35% (56 persons) reported all five restrictions as useless
to them. An important number of participants had a
health condition that could affect driving performances
(n=85, 52.5%). Further details on participating drivers
are provided in table 1.
Prevalence of moderate or severe CS loss
Twenty-one per cent (95% CI 15.0% to 28.1%) of drivers
had a moderate or severe CS loss for at least one eye. Twelve
cases having a severe loss (7.4%; 95% CI 3.9% to 12.6%).
We also observed two cases (1.2%; 95% CI 0.1% to 4.4%)
of CS loss in both eyes. The two cases we observed with
binocular CS loss were a 82-year-old male driver who had
severe binocular CS loss (log(CS)=1.28) without having
lost his VA (0.8 decimals), and a 78-year-old female driver
with a moderate CS loss of 1.48 log(CS) but a VA of 1.0
decimals. Both drivers had no cognitive deficits and were
given an excellent daytime on-road driving evaluation and
both reported only slightly limiting their night driving.
We also observed that drivers with low CS tended to also
have slower functional mobility, identified more self-im-
posed driving restrictions as being useful and had lower
VA (table 1).
Associations between VA and CS
When screening for vision, measuring VA alone had us
take into account 39.7% of the variance we observed
when measuring CS (P<0.001). One-third of the 39 tested
eyes that had a log(CS)<1.5 had a VA of 0.8 decimal or
better. Adding CS would have made it possible to detect

4 Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546

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Figure 2 Driving performances between drivers with normal
contrast sensitivity (CS) and those with low CS. (A) On-road
driving score ranges from 0 to 8 with higher scores indicating
more errors. (B) Driving restriction score ranges from 0 to 20
with higher scores indicating higher levels of restriction.
unsuspected vision deficits in 11 drivers (6.8%; 95% CI
3.4% to 11.8%).
Association and added value of CS for predicting the
perceived utility of self-imposed driving restrictions
Drivers were more likely (R2=0.116, P=0.004) to report
finding driving restrictions potentially useful if they had at
least one eye that had reduced CS (figure 2; table 2). This
was particularly the case for avoiding driving in the dark
(R2=0.056, P=0.022) and in fog (R2=0.083, P=0.001). The
only significant association for VA, on the other hand, was
between binocular loss and avoiding driving in the dark
(R2=0.065, P=0.010). The observed added value of using
CS instead of VA was, however, not significant (P=0.345).
We also observed that drivers who recognised the useful-
ness of any form of driving restriction were 3.1 times
more likely to have moderate CS loss for at least one eye
(CS ≤1.5 log(CS)). The association between loss of CS and
recognising the usefulness of driving restrictions remained
significant even after adjustment for cognitive decline,
motor function, age and gender.
Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546
Open Access
Association and added value of CS for predicting daytime on-
road driving performance
Daytime driving performance was unrelated to CS or VA
loss (figure 2; table 3).
DISCUSSION
In our study, one driver aged 70+ out of five (21%) had
a loss of CS (<1.5 log(CS)) in at least one eye. Further-
more, our results suggest that 6.8% of all drivers aged
70+ start experiencing difficulties in low illumination
without their VA being affected in normal light condi-
tions (VA ≥0.5 decimal). Our study confirmed the clear
association between CS loss and the perceived utility of
driving restrictions even if the added value of using CS
instead of VA was not significant. The feeling of impair-
ment was more related to only one eye being affected or
to having an important difference between the two eyes
than to binocular impairment. Our results also confirmed
that loss of CS had no association to daytime on-road
driving performance. Our results therefore reveal two
important facts about vision loss and driving. First, many
people consider restrictions as being useful when their
loss only concerns one eye and is not believed to affect
their driving performance. Second, standard on-road
driving evaluations have important limitations, given that
they cannot reveal the difficulties experienced in more
difficult situations with less light as reported by drivers.
This suggests that standard on-road tests should not be
considered as a gold standard for assessing fitness to drive
unless these tests are adapted to the conditions in which
difficulties might arise.
One of the strengths of this study is that it studies drivers
that had not been selected for medical reasons or due to
the fact that they had experienced driving difficulties. This
provides better indication on the usefulness of medical
screening procedures targeting all drivers. Considering
the worst eye also improved our understanding of what
causes people to consider driving restrictions. The limita-
tions of this study are the limited number of participants
with severe vision impairment and the limited precision
of our vision screening tests. Given very few drivers in our
sample had important CS loss in both eyes, we cannot
exclude that such conditions would also affect daytime
on-road evaluations. Furthermore, some participants
certainly wore glasses that did not optimally correct their
refraction abnormalities. The Mars test is performed at
reading distance (50 cm), whereas VA is tested at distance.
Therefore, some discrepancies between the results from
each test could arise from refraction problems instead of
indicating a true lack of association between VA and CS.
Finally, we did not collect information about past cata-
ract operations or present diagnosis of cataract, making it
difficult to document patterns in access to surgery.
When comparing our results to the existing literature,
other studies have found that driving with a loss of CS
or a loss of VA leads to drivers tending to report diffi-
culties experienced while driving.15 18 24 38 39 Difficulties
5
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Open Access

Table 2 Advantages of CS over VA for determining driving restriction

CS VA LR test between models*
2 2
Adjusted R † P value‡ Adjusted R † P value‡ P value
Both eyes
Driving when dark 0.045 0.065 0.065 0.010 0.750
Driving on the highway 0.095 0.609 0.097 0.438 0.999
Driving under foggy conditions 0.012 0.834 0.013 0.631 0.999
Driving on unknown roads 0.057 0.565 0.057 0.667 0.999
Driving in dense traffic 0.090 0.897 0.096 0.287 0.979
Driving restriction score 0.069 0.653 0.080 0.151 0.857
Worst eye
Driving when dark 0.056 0.022 0.037 0.147 0.778
Driving on the highway 0.096 0.528 0.097 0.447 0.999
Driving under foggy conditions 0.083 0.001 0.018 0.312 0.090
Driving on unknown roads 0.066 0.185 0.061 0.354 0.988
Driving in dense traffic 0.103 0.122 0.094 0.390 0.943
Driving restriction score 0.116 0.004 0.078 0.204 0.345
Difference between the eyes
Driving when dark 0.050 0.032 0.044 0.448 0.985
Driving on the highway 0.091 0.738 0.096 0.728 0.992
Driving under foggy conditions 0.080 0.001 0.012 0.339 0.077
Driving on unknown roads 0.066 0.104 0.056 0.303 0.945
Driving in dense traffic 0.099 0.116 0.089 0.336 0.942
Driving restriction score 0.113 0.004 0.072 0.271 0.292
*Best model over worst. P values under 0.05 would mean the test with the highest R2 is significantly better than the other visual test.
†Adjusted R2 for entire model. R2 corresponds to the test’s contribution in explaining restrictions and ranges from 0 to 1.
‡Significance of contribution of visual component.
CS, contrast sensitivity; LR, likelihood ratio; VA, visual acuity.

seem to arise especially in low illumination14 and increase
the probability of driving restrictions being required.
Restricting driving and avoiding driving at night, dawn
or dusk seem to be appropriate measures for reducing
risks.5 Men, more than women and people with cognitive
decline, often deny experiencing or simply do not expe-
rience any vision problems and therefore do not want
or do not feel the need to have their driving practices
restricted.14 40 41 This is one of the situations in which a
deeper visual screening is needed. However, restricted

Table 3 Advantages of CS over VA for determining on-road driving score (0–3)*

LR test between
CS VA models†
R2‡ P value§ R2‡ P value§ P value
Both eyes
On-road driving score (0–3) 0.0001 0.895 0.00 0.946 0.9935
Worst eye
On-road driving score (0–3) 0.0062 0.332 0.0037 0.454 0.824
Difference between the eyes
On-road driving score (0–3) 0.059 0.411 0.057 0.568 0.999
*Excellent=0, Good=1, Moderate=2, Poor=3.
†P values under 0.05 mean that CS improved the prediction of on-road driving scores compared with VA alone.
‡Crude R2 were used instead of adjusted R2 given values were close to 0 and adjustment methods become inadequate. R2 corresponds to
the test’s contribution in explaining on-road driving scores and ranges from 0 to 1.
§Significance of contribution of visual component.
CS, contrast sensitivity; LR, likelihood ratio; VA, visual acuity.

6 Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546

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driving has also been shown to reduce risks to the
minimum for those experiencing cognitive decline.42 We
conclude that recommendations to reduce driving in the
dark require at least the measurement of CS or the testing
of VA in low illumination.14 This has been recommended
by the Deutsche Ophthalmologische Gesellschaft since
2008 when evaluating fitness to drive.43 Existing on-road
tests, mainly done in high illumination, are not suited
for detecting difficulties related to loss of CS. If on-road
evaluation is to be considered as a reference standard for
fitness to drive, it might be necessary to adapt the driving
tests and also assess performances in places with low lumi-
nosity. In clinical settings, it might be relevant to test CS
using free, computer-based solutions or by simply ques-
tioning the drivers concerned.44 The vision and night
driving questionnaire (VND-Q) was developed for this
purpose and includes nine simple questions that drivers
can answer prior to their medical examination.45 46
We must not forget that a decrease in CS and/or VA47
can be the major symptom of several ocular disorders,
like cataracts, which affect half of adults by the time they
reach 75 years of age.6 Many people can live a long time
with a cataract before a diagnosis is made and surgery
is performed.22 Unfortunately, drivers with a cataract or
cataracts, even involving only one eye, have 2.5 times
more risk of causing a car crash than those without a
cataract.6 22 47 This is why general practitioners should be
very vigilant when patients talk about difficulties experi-
enced when driving at night or under foggy conditions.
Impaired vision should always be investigated even if
patients are reluctant, because it can often be corrected
with either medical or surgical management, with subse-
quent improvement of visual function.6 24 Following cata-
ract surgery, patients can often even drive again at night
and/or under foggy conditions with a decreased risk of
being involved in a car crash.6 Adequate management
might avoid unneeded self-restriction or, even worse,
unneeded driving cessation.
When assessing fitness to drive, the role of vision
screening is more about targeting appropriate driving
restrictions than recommending driving cessation.26
Some drivers expose themselves to excessive risks by
driving in the dark. On the other hand, many drivers,
especially women, tend to unnecessarily restrict their
driving due to vision deficits in one eye alone.19 Referring
patients to ophthalmologists, occupational therapists or
driving instructors to compensate appropriately for vision
loss in one eye could help some drivers overcome their
fear of driving.
CONCLUSION
Loss of CS could concern up to one older driver out
of five and often occurs without affecting VA. Those
with CS loss tend to be more likely to avoid driving at
night, in bad weather or under foggy conditions. Visual
screening including CS would help detect ophthalmic
diseases earlier and refer patients for surgery before their
Spreng L, et al. BMJ Open 2018;8:e018546. doi:10.1136/bmjopen-2017-018546
Open Access
condition affects their driving. This remains, however,
controversial given vision status was poorly associated to
driving performances for both VA and CS in this research
study. Further research is needed to evaluate the impact
of vision screening on road accidents.
Acknowledgements We thank Frederique Margot for calling all the participants
and setting up the appointments, the 12 driving instructors who assessed driving
performance, Sylvie Hautle and the Swiss Automobile Club for organising the
refresher courses and letting us use their facilities, and Dave Brooks (ELCS) for
editing our English.
Contributors PV and BF applied for and obtained the grants for this study. PV
wrote the protocol, managed the staff, recruited participants and monitored data
collection. BF was the principal investigator. LS and PV ran the analysis. LS, BF,
F-XB and PV interpreted the results; LS and PV wrote the manuscript; all authors
approved the final draft.
Funding This study was financed by a grant accorded for research in 2011 by
the Department of Medicine and Community Health of the University Hospital of
Lausanne, Switzerland.
Disclaimer The funder had no influence on the design, the collection, the analysis
and the interpretation of data; on the writing of the manuscript or on the decision to
submit the manuscript for publication.
Competing interests None declared.
Patient consent Obtained.
Ethics approval The protocol was approved by the official state ethics committee
for the Canton of Vaud (www.cer-vd.ch) under the reference CE 157/2011.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data is made available on request to the corresponding
author or francois.mooser@hefr.ch. It is not made publicly available for
confidentiality to be maintained. Health data could be linked and merged to
existing non-anonymised databases including those held by automobile insurance
companies.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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